Healthcare Provider Details

I. General information

NPI: 1093187502
Provider Name (Legal Business Name): IVO MIRTCHEV PHARMD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/22/2015
Last Update Date: 01/24/2020
Certification Date: 01/24/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4840 W DESERT INN RD
LAS VEGAS NV
89102-9125
US

IV. Provider business mailing address

1906 TANNER VALLEY CIR
LAS VEGAS NV
89123-2843
US

V. Phone/Fax

Practice location:
  • Phone: 702-248-1854
  • Fax: 702-248-7042
Mailing address:
  • Phone: 702-460-4364
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code183500000X
TaxonomyPharmacist
License Number18766
License Number StateNV
# 2
Primary TaxonomyY
Taxonomy Code1835P0018X
TaxonomyPharmacist Clinician (PhC)/ Clinical Pharmacy Specialist
License Number18766
License Number StateNV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: